Kim J. Masters, M.D.
I attended an international conference on “Examining the Safety of High-Risk Interventions for Children and Young People” sponsored by the Cornell University College of Human Ecology, Sterling University in Scotland, and the Child Welfare League of America. (See Cornell’s website for more information: http://rccp.cornell.edu/ symposium.htm.) The website has many presentations including some of those described below. About half of the 65 attendees presented papers. Maggie Bennington-Davis, M.D., and I were the only psychiatrists in attendance. Below are some of the highlights.
Finding #1: When patients die in restraint, most are in a prone (face down) position. How does this happen? From what I have seen, during restraints, children and adolescents often fall to the floor or the staff moves them to the floor by grabbing their legs, in part as a response to being kicked. Once on the floor, a staff member can position the child or adolescent in such a way that their breathing is compromised, for example if a staff person were to lay on top of a child.
What should we do about this information? It would be helpful to ensure that all holds do not compress airways. In training programs today “non compressing” restraints are taught. However, positions taught during training and their application by staff at the time of a restraint may differ, partly because of the high adrenaline level that these situations create. What next? Encourage staff and children and adolescents to sit or stand instead of moving to the floor during a restraint.
My first efforts in this endeavor failed. I counseled teenagers to “avoid prone restraint if at all possible because people are far more likely to die in prone restraint.” Unfortunately, this led to teens’ accusations that, “staff were trying kill them,” by using prone restraints.
Next I tried a modified approach: to inform both the staff and the children/ adolescents that prone restraints are more dangerous than other restraint positions and then to request that, in the case of a restraint, everything be done by both parties to keep the restraint in either a sitting or upright position. So now staff are working with the children for ways to keep restraints upright. I do not yet know if this will be effective.
Finding #2: A poster presentation by Michael Nunno, DSW, and other members of the College of Human Ecology examined the cause of death in 45 physical restraints. Twenty-nine (64%) of them were directly caused by suffocation.
Could these deaths have been prevented? The answer would require awareness of the oxygen status of those being restrained. For the last 10 years, reliable pulse oximeters, which measure oxygen saturation, have been available. Maybe oximetry could have helped rescue some of those who died. (I will discuss and explore on oximetry in a future column.)
Finding #3: Dr. Janice LeBel, Ed.D., a psychologist from the Massachusetts Department of Mental Health, conducted a cost analysis of the effects of a seclusion and restraint reduction program in an acute adolescent psychiatric service for aggressive adolescents. This program Dangers of prone restraint, causes of death during restraints, and the financial effects of restraint reduction efforts are a few of the findings from a recent international conference on the safety of high-risk interventions for children and adolescents. saved millions of dollars mostly by reduced staff and patient injury, reduced employee sick time, and increased staff retention due to increased job satisfaction.
Finding #5: David Day, Ph.D., presented a paper that reviewed the number of high quality studies on seclusion and restraint carried out over the past few years. Considering the frequency with which these procedures are employed, one would think that there would be clinical evidence of benefit. What Dr. Day showed, however, is that there is no such evidence. The few studies that have been done are flawed. Why aren’t there studies? Possibly, in part, because psychiatrists have not become involved. Another possibility is that it is not an attractive field to study in that it has no ready funding sources and it provides constant reminders of the effects of violence.
Finding #6: In a paper discussing the topic, “Are Restraints Ever Justified?,” Professor Wanda Mohr, who is an international expert on this subject, said, “no.” The paper discussed the medical and psychological sequellae of the restraint process and concluded that the risks of harm far outweigh any possible gains in staff control.
Finding #7: Can a hospital completely eliminate the use of seclusion and restraint? Yes. Maggie Bennington- Davis, M.D. and Tim Murphy, M.S. turned a Salem, OR psychiatric unit into a restraint and seclusion-free environment and have had no use of either of these procedures for several years. How? They changed their approaches to treatment so that instead of a hierarchy of staff at the top and patients at the bottom, a partnership was created which turned the psychiatric unit into a “therapeutic community.” This environment puts patients and staff on an equal “power” footing with one another. The result is reduced tension and hostility. Restraints and seclusions in many facilities are triggered when a patient breaks a unit rule, and triggers a staff “direction” or order. In a therapeutic community, decisions about rules are subject to community control, so these disagreements have the possibility of being resolved before escalating to physical violence. Dr. Bennington-Davis and Mr. Murphy’s paper is posted on the aforementioned Cornell University website.
Finding #8: Those at the conference who presented papers on the benefits of “therapeutic holding” and on restraint techniques, were mostly from companies that have a proprietary approach to their “specific” brand of safe holds and safe de-escalation talk. (I have reviewed some of these in past columns.) In other words, their companies make money teaching holds. One presenter argued forcefully that there were no really beneficial holds unless they were carried out on a special mat he had developed that was soft. I asked him if anyone could suffocate on the mat by having their nose obstructed but never got a satisfactory answer.
Finding #9: A paper I delivered on “Modernizing Seclusion and Restraint Monitoring and Equipment,” pointed out: 1) that the equipment we employ in this field is similar to that used by Dr. Philippe Pinel in 1794 (in what other medical-related field do we use 200-year-old instruments and forget the clinical observations of our predecessors?) and 2) that we often forget Dr. Pinel’s remarkable perspective on patient care, which is drawn directly from the guiding principles of the French Revolution—“Liberty, Equality, and Brotherhood”—in other words that those in our care should be accepted as brothers or sisters and treated with equality and allowed as much freedom as possible.
Overall, the conference reinforced for me the need for child and adolescent psychiatrists to become active partners in studying, sharing, listening, and working within this field for the safety and well-being of the children and adolescents we treat.
Dr. Masters is Chief Medical Officer of ABS New Hope Treatment Centers and Assistant Clinical Professor of Health and Behavior at the Medical College of Georgia.